Which of the following statements could be included in a definition of nursing diagnosis?
a. directly derived from pathological changes
b. directly derived from client responses
c. highly dependent on diagnostic test results
d. purpose is to remove or modify the cause of the disease
B
Nursing diagnosis, the second step of the nursing process, involves the analysis and synthesis of data gathered during the assessment phase to represent a clinical judgment about a client's responses to actual or potential health problems or life processes. A nursing diagnosis provides the basis for choosing nursing interventions to achieve desired client outcomes.
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After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?
a. "I don't drink milk because it gives me gas and diarrhea." b. "I have been taking digoxin every day for the last 15 years." c. "I take sodium bicarbonate after every meal to prevent heartburn." d. "In hot weather, I sweat so much that I drink six glasses of water each day."
A monofilament test is used to determine a client's risk for which of the following complications of diabetes mellitus?
A) diabetic ulcer of the foot B) diabetic retinopathy C) diabetic ketoacidosis D) arterial insufficiency of the lower extremities
Your patient, who is 42 years old, has requested a routine physical examination and states that she has not had one for several years.You observe a cauliflower-like lesion on the patient's cervix, which can indicate
a. carcinoma of the cervix. c. ectropion. b. cervical polyp. d. obstruction of the cervical glands.
A patient with swelling and a laceration above the right eye states, "I don't know what caused me to fall and cut my head on the door frame."
The patient's spouse appears nervous but smiles when mentioning that the patient is "so clumsy at times.". The nurse should give priority attention to which intervention when addressing this patient's needs? a. Directly asking the patient if spousal abuse is occurring or has ever occurred b. Completing a thorough assessment that includes a focus on signs of old injuries c. Interviewing the patient regarding the circumstances surrounding this suspicious fall d. Notifying security that there is a possibility that this patient is a victim of physical abuse